Spinal Anesthetic That Wears Off Before Surgery Ends

A 68-yr-old woman, previously healthy, is scheduled for a large inguinal hernia repair. She has a class 3 Mallampati score, weighs 104 kg, and is 5′5″ and has GERD (gastro-esophageal reflux disease). She tells you that a previous general anesthetic, not long ago, was complicated by great difficulty in securing the airway with an endotracheal tube. She was advised to tell any future anesthesiologist about this potential problem. She is nervous about a general anesthetic and requests a spinal anesthetic. You place an uneventful spinal at L3-4 with 1.4ml bupivacaine 0.5%. The spinal works well, and the surgery begins. Operative problems, mainly with lack of proper equipment, are encountered and the procedure that should have taken 30min is now at 2h and still ongoing. The patient begins to complain of pain. You give some sedation with midazolam up to 2mg and fentanyl up to 75mg, while the surgeon injects into the surgical site and around with 50ml of lidocaine 1%. Neither has much effect, as the patient still complains of pain and looks irritated by the whole proceedings. You consider an awake fiberoptic intubation, followed by a general anesthetic. Unfortunately, you are now told that all fiberoptic intubation equipment are being serviced and won’t be back before tomorrow. You dismiss the idea of more sedation and of inducing general anesthesia via facemask as too dangerous. The surgeon who is a friend of yours, and usually very reliable with his estimated surgical time, tells you that he will be only 10–15 min. You believe him, but what are you to do?